New Patient Form

Schedule Appointment

NOTE: If you are a new patient, please also fill out the New Patient Information Form here.

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Phone

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First Name*

M.I.*

Last Name*

Email Address*

Primary Phone Number*

Secondary Phone Number

Date of Birth*

Social Security Number

Address*

Street Address Address Line 2 City State ZIP Code

Gender*

Race*

Employer

Occupation

Do you wear contact lenses?*

Marital Status

Spouse's Name

Spouse's Date of Birth

Spouse's Employer

Medical History

Primary Care Physician

Primary Care Physician’s Phone Number

Please check if you have any of the following conditions:*

Diabetes

Glaucoma

Macular Degeneration

None of the above

Primary Insurance

Note: Please still bring all insurance cards with you to your appointment!

Responsible Party (Insurance Subscriber)

Member’s Date of Birth

Member’s SSN

Member’s Primary Phone Number

Member’s Address (if different from patient’s)

Street Address Address Line 2 City State ZIP Code

Privacy Policy

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Health Information Protection**

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Testimonials

    
 
 
       E C 
 October 31, 2026
 
 
  This was the third or fourth time that Dr Johnson  did an exam for glasses for me. They are always very friendly and professional.

I'm now waiting for my glasses after getting my prescription.

Everyone I dealt with was very pleasant and helpful.  Thank you Eyecare Specialties Staff.  I appreciate all of your help and friendliness.

Sincerely, Esther Caroline Payne
  
 
      C G 
 October 30, 2026
 
 
  Very professional service. Highly recommend. Thank you to Ashley, Kaylee, Tiffany, Tatiana and of course Dr. Hardy.
  
 
      N J 
 October 30, 2026
 
 
  The staff and Dr. Johnson were great. They were on time for my appointment and everything ran smoothly. They helped me choose new frames and I was in and out pretty quickly. Everyone was friendly and very helpful.
  
 
      R B 
 October 29, 2026
 
 
  Great staff and Doctor. Very attentive and good at explaining everything.
  
 
      A A 
 October 28, 2026
 
 
  Everyone was so nice and accommodating! I had a wonderful experience there and will definitely continue using them for all of my optometry needs!
  
 
      D R 
 October 28, 2026
 
 
  Very friendly ! , great glasses to pick from.
  
 
      S R 
 October 24, 2026
 
 
  Very friendly and knowledgeable staff.
  
 
      A M 
 October 23, 2026
 
 
  Staff are professional, courteous & helpful. Highly recommended :)
  
 
      T L 
 October 22, 2026
 
 
  It was fantastic and every person I dealt with was wonderful and very helpful.
  
 
      K H 
 October 22, 2026
 
 
  I had an unexpected eye emergency and they got me in immediately. Everyone was courteous and the visit was quick and easy. I will definitely be back for routine care!

New Patient Form

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Testimonials

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New Patient Form

Medical History

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Testimonials

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